Testing and Treatment
for Latent TB Infection in
Minnesota: What’s Next?
MDH TB Advisory Committee
April 8, 2010
Reported TB Cases*
United States, 1977–2009
No. of Cases
28,000
26,000
24,000
22,000
20,000
18,000
16,000
14,000
12,000
10,000
1977
1980
1984
1987
1990
1993
1996
1999
2002
2005
Year
*Updated as of March, 2010.
Adapted from CDC
2010
240
220
200
180
160
140
120
100
80
60
40
20
0
Year of Diagnosis
08
20
06
20
04
20
02
20
00
20
98
19
96
19
94
19
92
19
90
# TB cases
19
Number of Cases
Reported TB Cases, Minnesota,
1989-2009
Two thoughts…
Every TB case was once a
contact
The last hundred cases of TB
will be the most challenging to
eliminate
Close Exposure to TB
60-70%
Uninfected
90% Latent
TB Infection
30-40% Infected
10% Active
TB Disease
5% w/in
1-2 years
5% > 2
years
Latent TB Infection vs. Active TB Disease
Latent Infection
Active Disease
Positive
Usually positive
No
Usually
Normal
May be abnormal
Chest x-ray
Negative
Usually abnormal in
pulmonary disease
Infectious?
No
Pulmonary-Yes (before
treatment)
Extra pulmonary-No
Treatment
Optional
One drug (INH) for
9 months
Mandatory
3-4 drugs for
6-12+ months
No
Yes
Skin test (Mantoux)
Symptoms
Physical Exam
Report to Health
Department?
Latent TB Infection (LTBI)
 Estimated 5-10 million people in the U.S.

(~5% of population)
 Most U.S. cases result from reactivation of LTBI

Reactivation is the most infectious form of TB
 Persons with LTBI are the reservoir of future TB
Adapted from Ann Settgast, M.D.
March 2010
Active vs. Latent TB
Active TB disease
Latent TB infection
Why Treat LTBI?
 Trials done in 1960s-1970s: LTBI
treatment was 25%-92% effective
 If controlled for persons who were
compliant with the medication, efficacy
was ~90%
Targeted Tuberculin Testing and Treatment of
Latent Tuberculous Infection, CDC, 2000
Tuberculosis Cases by Risk Category*,
Minnesota, 2004-2008
Foreign-Born
Percentage of Cases
100
Substance
Abuse+
HIV-Infected
80
60
Other Medical
Condition**
Homeless
40
20
0
Risk Category
Nursing Home
Resident
Incarcerated
* Risk categories are not mutually exclusive.
†
Alcohol abuse and/or illicit drug use
** Conditions or therapies that increase risk for progression from latent TB infection to active
TB disease
TB Cases by Method of Case
Identification, Minnesota, 2004-2008
TB Contact
Investigation
(7%)
Refugee Health
Exam (domestic)
(6%)
Pre-immigration
exam (overseas)
(2%)
Other
(6%)
Presented with
Symptoms
(80%)
(N = 1,064)
Recommendations from
previous TBAC discussions (1)
 Outreach
MDH nurse or other staff
 More provider education and training
 Public education (including BCG)
 Community leaders outreach
 LTBI “hotline” at MDH

 Promote LTBI testing and treatment of
foreign-born who are not currently tested
(e.g., student, business, work visas)
Recommendations from
previous TBAC discussions (2)
 Use shorter LTBI treatment regimens
 Increase the use of incentives for LTBI
patients
 Use technology and other innovations to get
people treated for LTBI
Template database for clinics and LPH to use
to track patients on LTBI treatment
 Video/Phone “DOT”

Recommendations from
previous TBAC discussions (3)
 Promote widespread use of IGRA testing
 IGRA testing at MDH lab
 Analyze cost effectiveness of screening
employees with IGRA vs. TST
 Streamline referrals for LTBI patients who move
or change providers
 LTBI registry (mandatory or voluntary)
 State funding for local outbreaks and large CIs
 Support U of M research into improved
diagnostic methods
Current Models for LTBI Testing
and Treatment in MN (1)
 Public health TB contact investigations
 Class B and refugee testing
 Employee health (mandated)
 Worksite testing (not mandated)
 Correctional facility staff and inmates
 Colleges
 Schools
Current Models for LTBI Testing
and Treatment in MN (2)
 Primary care (including pediatrics)
 Specialty care
 Rheumatology
 HIV
 Adoption
 Travel
 Obstetrics
 Immigration physicals (civil surgeons)
 Military
 Homeless (?)
MDH role
 Consultation
 Develop and disseminate recommendations
 Tracking
Contact investigations
 Class B and refugee follow-up

 Collect, analyze & report TB surveillance data
 Provider education and training
 Public education materials
 Free TB medications
LTBI-related program objectives
(MDH)
 Contact investigations



Identify and evaluate people with known exposure to infectious
TB
Start LTBI treatment
Complete LTBI treatment
 TB Class B arrivals



Evaluate
Start LTBI treatment
Complete LTBI treatment
 Evaluate:


Why 13% of newly-infected contacts don’t start LTBI treatment
Why 35% of those who start LTBI treatment do not finish it
Possible future activities for
MDH
 LTBI “Toolkit” for clinics, LPH, jails, etc.
 Wallet card, etc
 Revise MDH LTBI recommendations (2003) and
school screening recommendations (2000)
 LTBI MEDSS module for local public health
 Work to expand insurance coverage for LTBI f/u visits
 Involve other partners





Affected communities
Health plans
Primary care clinics who see high-risk patients
Occupational health clinics
Worksites that do non-mandated TB testing
Questions
 Who are our highest priority groups?
 Who has highest risk of exposure to TB?
 Who has highest risk of active TB, if infected?
 Who can we realistically treat, given current
resources?
 How do we make sure they get tested for LTBI?
 How do we make sure they are started on LTBI
treatment?
 How do we make sure they finish treatment?
 Who are we losing? How?
 What has been successful?
What can MDH do within
the next 1-2 years?
What can other settings
do within the next 1-2
years?